Rebirth of a Clinic: A Design workbook for architecture in general practice and primary care
Graham Crist, Brendan Jones, Judy Evans (RACGP), Ian Watts (RACGP)
Canberra: The Royal Australian College of General Practitioners (RACGP), 2008
Through the School of Architecture and Design at RMIT, Antarctica directors Graham Crist and Brendan Jones collaborated with the Royal Australian College of General Practitioners to produce the design workbook Rebirth of the Clinic.
The workbook is designed as a scrapbook in which GPs, members of the practice team and architects can write notes, draw models and share ideas on designing primary health care facilities that will meet the long term needs of patients and staff.
“Through the development of this workbook we have kept in touch with the needs of grassroots doctors and their teams to ensure the design suggestions reflect the reality on the ground,” said Dr Huy Quoc An, a member of the RACGP National Standing Committee – GP Advocacy and Support.
RMIT Architecture program director Graham Crist notes that design is often seen as something supplementary or decorative especially in a field where there are urgent needs and urgent budget issues. “We have to articulate the fact that design isn’t a luxury item,” he says. “It’s something that can be embedded in the quality of the practice experience. And it doesn’t need to cost any more to make a difference.”
Good design considers the current challenges for general practices, such as the increasing size of multidisciplinary teams, educational needs within the practice, the streamlining of chronic and acute care, and the importance of safety for patients and staff.
“There’s no reason why someone can’t bring design principles into a very minor refit,” says Crist. “We saw GP clinics designed by doctors where they’d done a fantastic job refitting a house and making something quite special with no major spatial or architectural work.”
National Radio Interview:
Design and the Doctors Surgery
Host: Alan Saunders
Dr Huy Quoc An, Royal Australian College of General Practitioners
Graham Crist, RMIT Architecture Senior Lecturer, Practice Director: Antarctica
When you visit your doctor perhaps the design of the waiting and consultation rooms is the last thing on your mind. And many doctors might think that aesthetics take a back seat to the primary function of a medical clinic. But should they? Can’t design help play a role in making us feel better?
REBIRTH OF THE CLINIC
Architectural design for general practice
Lowerpool Design Studio
RMIT Bachelor of Architecture, Semester 1, 2007
Studio Leaders: Graham Crist and Brendan Jones, Practice: Antarctica
Ian Watts (RACGP)
Gerard Fox (RACGP)
The Studio Methodology
The process of developing a GP Clinic Design Guide document commenced at RMIT by carrying out a design studio with architecture students, with the task of designing hypothetical clinics in Melbourne, Victoria. This is a well tested method at RMIT, where research is carried out in the medium of design and in the teaching environment. Questions are tested by `doing’ in a speculative manner and the design process for a real project is simulated. The process merges research and practice and provides material that allows reflection on a question, which provokes further questions.
A group of 15 students at second and third year level signed up for the project to be carried out over 12 weeks. They were provided with a broad brief from the RACGP, and one of two pieces of land as the imagined location for a new medical practice. Each design would then act as a case study both demonstrating specific design responses and principles applicable elsewhere.
One site was small and constrained, on a busy road in inner city South Melbourne. The second was located on an existing car park in outer suburban Broadmeadows, within a civic/commercial precinct containing a large shopping centre, council offices and railway station.
In each case, the precedent for the design was loosely based on a real clinic located nearby. Work in progress was reviewed twice per week with input from both architects and the RACGP. Once preliminary designs were produced, we presented the work at the RACGP Annual Scientific Convention in Sydney, both as a short lecture and as informal discussion of the drawings between doctors and participating students.
The studio’s design outcomes pose broad questions rather than solve specific problems. They focus on questions of the clinics place in its environment – on a contemporary image for clinics and some of their spatial qualities. Once completed, the work was presented, examined and exhibited at RMIT and then made available as a set of test cases for elaboration in the design document.
Conference paper – Design Project Case Studies:
“The Rebirth of the Clinic: Case studies in architectural design for general practice”
Graham Crist, RMIT Architecture Senior Lecturer, Practice Director: Antarctica
50th RACGP Annual Scientific Conference, 2007
RMIT Openline Article:
A new vision for general practice design
November 03, 2008
RMIT University and The Royal Australian College of General Practitioners have produced a guide to designing general practices and primary health care facilities.
RMIT Architecture, together with The Royal Australian College of General Practitioners (RACGP), launched a new architectural workbook to guide general practitioners and architects in designing safe and effective workplaces.
The workbook, Rebirth of a clinic – an architectural workbook for general practice and primary care, is a practical and innovative resource that provides a guide to designing general practices and primary health care facilities in a way that meets the long-term needs of patients and staff.
RMIT Architecture Program Director, Graham Crist said the workbook was designed as a scrapbook in which GPs, the practice team and their architects could write notes, draw models and share ideas.
“Designing and building a general practice can be a daunting task and requires consideration of the spatial environment and the configuration of the health care setting,” said Mr Crist said.
“The key message that comes out is that design can play a vital role in the quality of the environment and in turn the quality of the patient experience.”
RACGP President, Dr Vasantha Preetham, said the addition of multi-disciplinary clinicians, practice nurses and other allied health professionals meant there were new design challenges in ensuring safety and effectiveness in general practice surgeries.
“As a profession, we need general practices to be a haven where the sick and the frail can obtain the care they need in a safe and comfortable environment.
“We want general practice surgeries to remain hubs of their community,” he said.
“We are very pleased that the RMIT University, through its School of Architecture and Design, has recognised the importance of this task, and brought its significant architectural expertise to the task.”
RACGP Media Release:
A new vision for General Practice Design
Rebirth of a Clinic – Architectural Workbook Launch
3 June 2008
The Royal Australian College of General Practitioners (RACGP), together with the RMIT School of Architecture and Design, is launching a new architectural workbook to guide general practitioners and architects in designing safe and effective workplaces.
The launch is being held at 6.30pm on Friday 6 June 2008 at Tjanabi located in The Atrium at Federation Square , Flinders Street , Melbourne .
“Our profession is evolving, general practice is welcoming multi-disciplinary clinicians into our teams; we are working closely with practice nurses and other allied health professionals to deliver care to our patients. As our workplace changes, there are new challenges in how we design our practices to ensure safety and effectiveness for patients and staff,” said Dr Vasantha Preetham, RACGP President and Perth-based GP.
The new RACGP resource is called Rebirth of a clinic – an architectural workbook for general practice and primary care and is a practical and innovative resource that provides a guide to designing general practices and primary health care facilities in a way that meets the needs of patients and staff into the long term.
“Sadly, workplace violence is a significant problem in general practice; with one recent Australian study suggesting that as many as two in three GPs are exposed to work-related violence in any 12-month period.
“As a profession, we need general practices to be a haven where the sick and the frail can obtain the care they need in a safe and comfortable environment. We want general practice surgeries to remain hubs of their community,” said Dr Preetham.
“We are very pleased that the RMIT University, through its School of Architecture and Design, has recognised the importance of this task, and brought its significant architectural expertise to the task”, Dr Preetham added.
“ Through the development of this workbook we have kept in touch with the needs of grassroots doctors and their teams to ensure the design suggestions reflect the reality on the ground,” said Dr Huy Quoc An, member of RACGP National Standing Committee – GP Advocacy and Support.
“I want to thank those doctors and their teams who have spent their valuable time and have shared their knowledge and experience with their colleagues and the Faculty of Architect at RMIT University and those students who have put so much effort into this guide; their spirit of innovation and their passion to solve these new design challenges in general practice is inspirational,” said Dr Huy Quoc An.
“The workbook is designed as a scrapbook in which GPs, the practice team and their architects can write notes, draw models and share ideas. Designing and building a general practice can be a daunting task and requires consideration of the spatial environment and the configuration of the health care setting,” said Graham Crist, RMIT Architecture Program Director.
“The key message that comes out of the study is that design can play a vital role in the quality of the environment and in turn the quality of the patient experience,” said Graham Crist.
Rebirth of a clinic suggests that good design will ensure that:
* a general practice is suited to the particular needs of the community it serves
* a general practice is environmentally aware and engages design features to improve building sustainability and reduce the carbon footprint.
* the available knowledge about design is readily available to architects and doctors
* work spaces like reception and waiting room areas are organised, inviting, offer privacy, ambience and a stress free environment
* treatment and sterilisation areas have ‘dirty to clean’ flows, clear and functional workflow patterns, efficient storage of consumables, and the right equipment at the bedside to care for patients
* consulting rooms have two exits, little ambient noise and sufficient natural and artificial light that is focused over work areas.
Good design also considers the current challenges for general practices:
* the increasing size of multidisciplinary teams
* a focus on education
* the streamlining of chronic and acute care
* the importance of safety for patients and staff.
Putting Design into Practice
GP Review, March 2008 Volume 12 Number 1
“This is more than an exercise in aesthetics: it’s about solving very real problems of space and environment, so that GPs aren’t faced with the irony of practising the healing art in a sick building.”
Western Australian general practitioner Dr Shiong Tan is thinking about his practice: not just the kind of care he provides, but also the brick and mortar surroundings in which he provides it. Dr Tan’s practice has outgrown its original architecture. The mix of acute and chronic care patients he and his colleagues treat at their group practice in Perth has changed in the ten years since the practice was originally built. “It worked well for a while,” says Tan, “but we realised that to run both kinds of care we need an efficient patient flow. We can’t do it the way the practice is physically structured, and we don’t have the luxury of dispensing with the building and starting again.”
Dr Tan and his colleagues are planning to add an extra 220 square metres to the practice – but Tan knows that extra space alone won’t solve the problem of keeping his flow of quick visit, acute care patients distinct from his longer visit, chronic care patients. More important is how the space is actually used to triage and accommodate waiting patients, to have them seen by practice nurses and doctors, and to get them to the billing desk and home again.
“We made the decision to carve out a different flow for our acute and chronic care patients so we could give uninterrupted care in a timely fashion.”
For Dr Tan and his colleagues, this means thinking about how the design of their practice can best serve the health care they provide, instead of providing health care within the constraints of their working environment.
It’s this kind of thinking that has helped produce a gradual evolution in workplace design. While conventional office buildings continue to hem staff into stale grey cubicle honeycombs, the dotcom era has seen a flowering of more innovative and adventurous working environments.
Employees of the internet goliath Google, for example, hold meetings on couches, enjoy twice weekly roller hockey matches in the car park, and have access to video games, ping pong tables and even a baby grand piano. And at the space age London offices of energy drink manufacturer Red Bull, staff and visitors have the choice of conveying themselves between floors by means of a retrofuturistic slippery slide.
These vibrant workplaces reflect the nature of the companies behind them. But general practice – diverse, innovative and community-centred – often operates in environments that are not only unreflective of the profession, but are demonstrably unsuited to the services that GPs provide. Consider the classic converted period home: rich in character but lacking in practicality, with narrow central corridors inviting bottlenecks and restricting communication between GPs and practice staff.
At the other extreme, the modern converted office or shopfront has the potential to be sterile in the most undesirable sense of the word.
In the pursuit of excellence
Practice design is a real issue. “We know that a pleasant workplace improves the wellbeing of our patients and our teams,” says RACGP President Dr Vasantha Preetham. “We know that the care we provide can be enhanced by investing in the environment in which we work – be it a reliable stethoscope or a whole practice.”
General practitioners aren’t blind to this– far from it. Each week, the RACGP receives enquiries from GPs seeking realistic guidance on how to design or redesign their practices. This is more than an exercise in aesthetics: it’s about solving very real problems of space and environment, so that GPs aren’t faced with the irony of practising the healing art in a sick building.
In 1984, the RACGP produced a handbook for GPs entitled The design of doctors’ surgeries. The handbook offered practical advice for correcting common design faults such as poor climate and sound control, lack of parking space and suitable entrances for people with restricted mobility, inadequate signposting, dysfunctional layout, ill fitting and undersized consulting rooms, and inadequate space for staff facilities. These issues are as important today as they were in 1984 – but advances in general practice, architecture and technology have highlighted the need for a new handbook to meet the design, workplace and environmental challenges of the twenty-first century. The result is an evidence based handbook that GPs will be able to use to solve design issues in their existing practices and to communicate their desires and intentions to an architect, designer or tradesperson.
Flexible designs for a diverse profession
The first step in developing a new handbook for GPs was to define excellence in practice design. Work began in July 2007, when the RACGP formed a partnership with RMIT Architecture – a meeting of industry leaders in health and architecture to marry ‘best practice’ design with the needs of GPs, practice staff and other health care professionals. The result of this partnership – involving close collaboration with RMIT Architecture lecturers Graham Crist and Brendan Jones – is a set of principles that the RACGP and RMIT believe underpin design excellence (see above). Recognising the diversity of general practice, for example, the design principles in the updated handbook are applicable to both large and small practices, and take into account the expanded range of services GPs offer. The handbook also offers advice on adapting design ideas across the range of environments in which general practice operates, from the tropical north to southern snowfields, and from remote outback locations to the inner city surgery. Flexibility extends to how space is used within the practice. Not all practices will be able to invest in building teaching rooms, meeting rooms, student rooms, allied health rooms and dedicated spaces for learning and creativity. The new handbook shows GPs how they can design spaces that are flexible enough to suit multiple purposes.
Communication and community
Primary health care typically begins with a conversation between patient and doctor, and colour and light are essential in creating a space in which patients feel comfortable enough to communicate effectively with GPs and practice staff. Gordon Young, one of the authors of the original The design of doctors’ surgeries, suggested that a ‘poor standard of decor’ was perhaps a greater problem in general practice design than any functional deficiency. “Patients don’t want to go to a corporate looking medical centre,” says Dr Tan. “They want to feel at home.” It’s important not just for the patient to feel at home, but for the practice to appear at home in its surroundings. A design that integrates a practice with its environment reinforces the idea that general practice is at the heart of the community. RMIT Architecture student Yongpeng Sheng’s concept for a practice located on a busy inner city road is a blend of the manmade and natural worlds. The facade is latticed with long, thin windows running the length and height of the building, echoing the trunks and branches of the tall gum trees located on the site. The result is that the trees seem to cast shadows that penetrate into the building itself, opening the practice to the neighbourhood while preserving the intimacy and privacy of the consulting space.
Not all GPs will be seeking to redesign their practices so dramatically. The purpose of the new handbook is to help GPs take advantage of evidence based design to solve problems, and to explore creative but cost effective possibilities for their practices – whether they’re renovating an individual consulting room or building an entire medical centre. “We need dialogue between general practice and the architecture profession,” says Dr David Oberklaid, whose South Melbourne practice was one of a number of clinics visited by RMIT Architecture students. “I think all of us would welcome ideas on how to better design and improve our practices. This is a first step, and we need to continue the dialogue.”
Meanwhile, Dr Tan and his colleagues have been working with an architect to solve some of their constraint issues and to explore ways of separating their acute and chronic care patient flows. One of the ideas that has sprung from this collaboration is the idea of installing half a dozen patient assessment ‘pods’ fitted with biometric instruments and data connections: an alternative to the traditional assessment area and a smarter use of the available space. “In systematic chronic disease recall care you don’t need a bed for the patient,” says Tan. “Instead, the patient can have their biometrics measured by the practice nurse in one of these pods and then move straight to see the doctor, where they can spend time specifically discussing long term issues.” The updated design guide for general practice will be published in May.
The D.E.S.I.G.N. brief
• General practice is diverse. Practice designs must be suited to particular environments and allow for flexibility into the future.
• General practice needs to be economically sustainable. General practitioners must be able to take advantage of the latest techniques and ideas in building cost friendly practices.
• General practice needs to be safe, both for patients and practice staff. Reducing the threat of emotional or physical harm to staff and patients may involve hands free sinks (to reduce spread of disease), reductions in ambient noise and greater access to natural light.
• General practitioners are interested in innovation. The new generation of medical graduates have come of age in a culture of innovative technology and new forms of electronic communication. This may be reflected by creating space for group education sessions and incorporating wireless technologies.
• General practice seeks to be ‘green’, with environmentally sustainable, ‘low impact’ clinics that place low demands on water and electricity. General practice also has a role in promoting environmental awareness for the ultimate health benefit of the community.
• General practice is ‘neighbourly’, and is situated at the heart of a community’s health.